Gives information about the Observations section

Important: This specification is based on the Professional Records Standards Body's Pharmacy information flows standard which provides further information on document headings and content: https://theprsb.org/standards/pharmacyinformationflows1and2/

Clinical Observations for Minor Illness Referral Consultation (MIRC)

The Observations section carries details related to the patient’s observations. The list of coded Clinical Observations has been defined as:

• Blood Pressure
• Pulse Rate
• Temperature
• Height
• Weight
• Oxygen Saturation
• Pain Score
• Level of Consciousness
• Respiratory Rate
• Air or Oxygen
• NEW2 Score

Elements should be rendered as subheadings in any HTML sent.

Example Clinical Observations for Minor Illness Referral Consultation (MIRC) Section

Note: These examples have not been clinically assured against Digital Medicines use cases.
Examples are illustrative only.

<!--<xml>-->
<!--Observations-->
<section>
	<title value="Observations"/>
	<code>
		<coding>
			<system value="http://snomed.info/sct"/>
			<code value="1102421000000108"/>
			<display value="Observations"/>
		</coding>
	</code>
	<text>
		<status value="additional"/>
		<div xmlns="http://www.w3.org/1999/xhtml">
			<table width="100%">
				<tbody>
					<tr>
						<th>Observation</th>
						<th>Performed</th>
						<th>Reading</th>
					</tr>
					<tr>
						<td>Respiration rate</td>
						<td>2021-02-08T12:34:04</td>
						<td>38 /min</td>
					</tr>
					<tr>
						<td>Pulse rate</td>
						<td>2021-02-08T12:35:15</td>
						<td>92 /min</td>
					</tr>
					<tr>
						<td>Oxygen saturation</td>
						<td>2021-02-08T12:36:45</td>
						<td>98%</td>
					</tr>
					<tr>
						<td>Air or oxygen</td>
						<td>2021-02-08T12:36:55</td>
						<td>Air</td>
					</tr>
					<tr>
						<td>Temperature</td>
						<td>2021-02-08T12:37:30</td>
						<td>37 C</td>
					</tr>
					<tr>
						<td>Systolic pressure</td>
						<td>2021-02-08T12:39:34/td>
						<td>84 mmHg</td>
					</tr>
					<tr>
						<td>Consciousness score</td>
						<td>2021-02-08T12:40:01</td>
						<td>voice</td>
					</tr>
					<tr>
						<td>NEWS2</td>
						<td>2021-02-08T12:40:15</td>
						<td>6</td>
					</tr>
				</tbody>
			</table>
		</div>
	</text>
</section>

<!--</xml>-->

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Coded Resources

The text section should be linked to the following FHIR resources to provide the textual information in a coded format.

Blood Pressure Observation

The coded form of each blood pressure reading follows the codes and structure for CareConnect-BloodPressure-Observation-1.

CareConnect-Observation-1 element	Cardinality	Notes
meta.profile	1..1	Claim conformance to ‘https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-BloodPressure-Observation-1’
status	1..1	Fixed to final
category	1..1	Fixed as per profile
code	1..1	Loinc slice – fixed as per profile SNOMED slice – fixed as per profile
subject	1..1	Link to Patient
effectiveDateTime	1..1	The date and time the blood pressure reading took place
performer	0..*	Either - use the identifier part of Reference data type to hold the identifier of the practitioner - use the display part of the Reference data type to hold the name of the practitioner - use the reference to point to a CareConnect-Practitioner-1 - use the reference to point to the Organization (pharmacy)
dataAbsentReason	0..1	An optional reason why the data is absent
comment	0..1	Any additional comments
bodySite	0..1	Optional body site of reading
component systolic
- code	1..1	Loinc slice – fixed as per profile SNOMED slice – fixed as per profile
- valueQuantity	0..1	Recorded as per the profile
- dataAbsentReason	0..1	A reason the data is absent
component diastolic
- code	1..1	Loinc slice – fixed as per profile SNOMED slice – fixed as per profile
- valueQuantity	0..1	Recorded as per the profile
- dataAbsentReason	0..1	A reason the data is absent

Blood Pressure Observation Example

Note: These examples have not been clinically assured against Digital Medicines use cases.
Examples are illustrative only.

<!--<xml>-->
<Observation xmlns="http://hl7.org/fhir">
	<id value="f80fc9e3-a4fe-400e-8fe4-83f7d5616ea2"/>
	<meta>
		<!--claim conformance to CareConnect-BloodPressure-Observation-1-->
		<profile value="https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-BloodPressure-Observation-1"/>
	</meta>
	<!--a fixed value for status-->
	<status value="final"/>
	<!--fixed value for category-->
	<category>
		<coding>
			<system value="http://hl7.org/fhir/observation-category"/>
			<code value="vital-signs"/>
			<display value="Vital Signs"/>
		</coding>
	</category>
	<!--fixed values for code-->
	<code>
		<coding>
			<system value="http://loinc.org"/>
			<code value="85354-9"/>
			<display value="Blood pressure panel with all children optional"/>
		</coding>
		<coding>
			<system value="http://snomed.info/sct"/>
			<code value="75367002"/>
			<display value="Blood pressure"/>
		</coding>
	</code>
	<!--a link to the Patient-->
	<subject>
		<reference value="Patient/4f78d392-c9e0-4f1f-9ab6-57d387838690"/>
	</subject>
	<!--the date and time of the reading-->
	<effectiveDateTime value="2018-10-04T14:17:59+01:00"/>
	<!--example of a link to a Practitioner-->
	<performer>
		<reference value="Practitioner/2360aba6-8561-4a22-bbbf-afc08e750146"/>
	</performer>
	<!--an example of the name of the practitioner-->
	<performer>
		<display value="DAVIES Gemma"/>
	</performer>
	<!--example of a link to the pharmacy-->
	<performer>
		<reference value="Organization/cd5f7770-6249-4f5d-ad8e-d0bb1446a4d9"/>
	</performer>
	<!--body site of reading-->
	<bodySite>
		<coding>
			<system value="http://snomed.info/sct"/>
			<code value="368209003"/>
			<display value="Right arm"/>
		</coding>
	</bodySite>
	<!--systolic-->
	<component>
		<!--fixed values for code-->
		<code>
			<coding>
				<system value="http://loinc.org"/>
				<code value="8480-6"/>
				<display value="Systolic blood pressure"/>
			</coding>
			<coding>
				<system value="http://snomed.info/sct"/>
				<code value="72313002"/>
				<display value="Systolic blood pressure"/>
			</coding>
		</code>
		<!--the systolic reading-->
		<valueQuantity>
			<value value="120"/>
			<unit value="mmHg"/>
			<system value="http://unitsofmeasure.org"/>
		</valueQuantity>
	</component>
	<!--diastolic-->
	<component>
		<!--fixed values for code-->	
		<code>
			<coding>
				<system value="http://loinc.org"/>
				<code value="8462-4"/>
				<display value="Diastolic blood pressure"/>
			</coding>
			<coding>
				<system value="http://snomed.info/sct"/>
				<code value="1091811000000102"/>
				<display value="Diastolic arterial pressure"/>
			</coding>
		</code>
		<!--the diastolic reading-->
		<valueQuantity>
			<value value="60"/>
			<unit value="mmHg"/>
			<system value="http://unitsofmeasure.org"/>
		</valueQuantity>
	</component>
</Observation>
<!--</xml>-->

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Temperature Observation

The coded form of each temperature reading follows follows the codes and structure for CareConnect-BodyTemperature-Observation-1

CareConnect-BodyTemperature-Observation-1 element	Cardinality	Notes
meta.profile	1..1	Claim conformance to ‘https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-BodyTemperature-Observation-1’
status	1..1	Fixed to final
category	1..1	Fixed as per profile
code	1..1	Loinc slice - system fixed to http://loinc.org - code fixed to “8310-5” SNOMED CT slice - system fixed to http://snomed.info/sct - code fixed to “276885007” - display ”Core body temperature”
subject	1..1	Link to Patient
effectiveDateTime	1..1	The date and time the reading took place
performer	0..*	Either: - use the identifier part of Reference data type to hold the identifier of the practitioner - use the display part of the Reference data type to hold the name of the practitioner - use the reference to point to a CareConnect-Practitioner-1 - use the reference to point to the Organization (pharmacy)
valueQuantity	0..1	The temperature recorded in Celsius
dataAbsentReason	0..1	An optional reason why the data is absent
comment	0..*	Any additional comments
bodySite	0..1	Optional body site of reading

Temperature Observation Example

Note: These examples have not been clinically assured against Digital Medicines use cases.
Examples are illustrative only.

<!--<xml>-->
Observation xmlns="http://hl7.org/fhir">
	<id value="dbbad20f-e696-405e-8c98-be0cdcc5406c"/>
	<meta>
		<!--claims conformance to CareConnect-BodyTemperature-Observation-1-->
		<profile value="https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-BodyTemperature-Observation-1"/>
	</meta>
	<!--fixed value for status-->
	<status value="final"/>
	<!--fixed value for category-->
	<category>
		<coding>
			<system value="http://hl7.org/fhir/observation-category"/>
			<code value="vital-signs"/>
			<display value="Vital Signs"/>
		</coding>
	</category>
	<!--fixed values for code-->
	<code>
		<coding>
			<system value="http://loinc.org"/>
			<code value="8310-5"/>
			<display value="Body temperature"/>
		</coding>
		<coding>
			<system value="http://snomed.info/sct"/>
			<code value="/276885007"/>
			<display value="Core body temperature"/>
		</coding>
	</code>
	<!--link to patient-->
	<subject>
		<reference value="Patient/4f78d392-c9e0-4f1f-9ab6-57d387838690"/>
	</subject>
	<!--date time when reading occurred-->
	<effectiveDateTime value="2018-10-04T14:17:59+01:00"/>
	<!--the performer-->
	<performer>
		<reference value="Performer/2360aba6-8561-4a22-bbbf-afc08e750146"/>
	</performer>
	<performer>
		<reference value="Organization/cd5f7770-6249-4f5d-ad8e-d0bb1446a4d9"/>
	</performer>
	<!--the reading-->
	<valueQuantity>
		<value value="38.5"/>
		<unit value="Cel"/>
		<system value="http://unitsofmeasure.org"/>
	</valueQuantity>
</Observation>
<!--</xml>-->

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Pulse Rate Observation

The coded form of each pulse rate reading follows the codes and structure for CareConnect-HeartRate-Observation-1.

CareConnect-Observation-1 element	Cardinality	Notes
meta.profile	1..1	Claim conformance to ‘https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-HeartRate-Observation-1’
status	1..1	Fixed to final
category	1..1	Fixed as per profile
code	1..1	Loinc slice – fixed as per profile SNOMED slice – fixed as per profile There could be a further SNOMED coding to narrow heart rate to pulse rate (see example below)
subject	1..1	Link to Patient
effectiveDateTime	1..1	The date and time the reading took place
performer	0..*	Either - use the identifier part of Reference data type to hold the identifier of the practitioner - use the display part of the Reference data type to hold the name of the practitioner - use the reference to point to a CareConnect-Practitioner-1 - use the reference to point to the Organization (pharmacy)
valueQuantity	0..1	The pulse rate recorded in beats per minute (/min)
dataAbsentReason	0..1	An optional reason why the data is absent
comment	0..1	Any additional comments
bodySite	0..1	Optional body site of reading

Pulse Rate Observation Example

Note: These examples have not been clinically assured against Digital Medicines use cases.
Examples are illustrative only.

<!--<xml>--> 
<Observation xmlns="http://hl7.org/fhir">
	<id value="a1f2519e-3cb1-4ba4-820a-57e47334b655"/>
	<meta>
		<!--claims conformance to CareConnect-HeartRate-Observation-1-->
		<profile value="https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-HeartRate-Observation-1"/>
	</meta>
	<!--fixed value for status-->
	<status value="final"/>
	<!--fixed value for category-->
	<category>
		<coding>
			<system value="http://hl7.org/fhir/observation-category"/>
			<code value="vital-signs"/>
			<display value="Vital Signs"/>
		</coding>
	</category>
	<!--fixed values for code, plus an extra SNOMED code for pulse rate-->
	<code>
		<coding>
			<system value="http://loinc.org"/>
			<code value="8867-4"/>
			<display value="Heart rate"/>
		</coding>
		<coding>
			<system value="http://snomed.info/sct"/>
			<code value="364075005"/>
			<display value="Heart rate"/>
		</coding>
		<coding>
			<system value="http://snomed.info/sct"/>
			<code value="78564009"/>
			<display value="Pulse rate"/>
			<userSelected value="true"/>
		</coding>
	</code>
	<!--link to patient-->
	<subject>
		<reference value="Patient/4f78d392-c9e0-4f1f-9ab6-57d387838690"/>
	</subject>
	<!--the date and time of the reading-->
	<effectiveDateTime value="2018-10-04T14:17:59+01:00"/>
	<!--example of a link to a Practitioner-->
	<performer>
		<reference value="Practitioner/2360aba6-8561-4a22-bbbf-afc08e750146"/>
	</performer>
	<!--an example of the name of the practitioner-->
	<performer>
		<display value="DAVIES Gemma"/>
	</performer>
	<!--example of a link to the pharmacy-->
	<performer>
		<reference value="Organization/cd5f7770-6249-4f5d-ad8e-d0bb1446a4d9"/>
	</performer>
	<!--the pulse rate reading-->
	<valueQuantity>
		<value value="95"/>
		<unit value="/min"/>
		<system value="http://unitsofmeasure.org"/>
	</valueQuantity>
</Observation>
<!--</xml>-->

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Height Observation

The coded form of each height reading follows the codes and structure for CareConnect-Observation-1.

CareConnect-VitalSigns-Observation-1 element	Cardinality	Notes
meta.profile	1..1	Claim conformance to ‘https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-VitalSigns-Observation-1’
status	1..1	Fixed to final
category	1..1	Fixed as demonstrated in example below
code	1..1	Fixed as demonstrated in example below
subject	1..1	Link to Patient
effectiveDateTime	1..1	The date and time the reading took place
performer	0..*	Either - use the identifier part of Reference data type to hold the identifier of the practitioner - use the display part of the Reference data type to hold the name of the practitioner - use the reference to point to a CareConnect-Practitioner-1 - use the reference to point to the Organization (pharmacy)
valueQuantity	0..1	The height recorded in metres or centimetres
dataAbsentReason	0..1	An optional reason why the data is absent
comment	0..1	Any additional comments
bodySite	0..1	Optional body site of reading

Height Observation Example

Note: These examples have not been clinically assured against Digital Medicines use cases.
Examples are illustrative only.

<!--<xml>-->  
<Observation xmlns="http://hl7.org/fhir">
	<id value="dbbad20f-e696-405e-8c98-be0cdcc5406c"/>
	<meta>
		<!--claims conformance to CareConnect-Observation-1-->
		<profile value="https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Observation-1"/>
	</meta>
	<!--fixed value for status-->
	<status value="final"/>
	<!--fixed value for category-->
	<category>
		<coding>
			<system value="http://hl7.org/fhir/observation-category"/>
			<code value="vital-signs"/>
			<display value="Vital Signs"/>
		</coding>
	</category>
	<!--fixed values for code-->
	<code>
		<coding>
			<system value="http://loinc.org"/>
			<code value="8302-2"/>
			<display value="Body height"/>
		</coding>
		<coding>
			<system value="http://snomed.info/sct"/>
			<code value="50373000"/>
			<display value="Body height"/>
		</coding>
	</code>
	<!--link to patient-->
	<subject>
		<reference value="Patient/4f78d392-c9e0-4f1f-9ab6-57d387838690"/>
	</subject>
	<!--date time when reading occurred-->
	<effectiveDateTime value="2018-10-04T14:17:59+01:00"/>
	<!--the performer-->
	<performer>
		<reference value="Performer/2360aba6-8561-4a22-bbbf-afc08e750146"/>
	</performer>
	<performer>
		<reference value="Organization/cd5f7770-6249-4f5d-ad8e-d0bb1446a4d9"/>
	</performer>
	<!--the reading-->
	<valueQuantity>
		<value value="175"/>
		<unit value="cm"/>
		<system value="http://unitsofmeasure.org"/>
	</valueQuantity>
</Observation>
<!--</xml>-->

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Weight Observation

The coded form of each weight reading follows the code and structure for CareConnect-Observation-1.

CareConnect-Observation-1 element		Notes
meta.profile	1..1	Claim conformance to ‘https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Observation-1’
status	1..1	Fixed to final
category	1..1	Fixed as demonstrated in example below
code	1..1	Fixed as demonstrated in example below
subject	1..1	Link to Patient
effectiveDateTime	1..1	The date and time the reading took place
performer	0..*	Either - use the identifier part of Reference data type to hold the identifier of the practitioner - use the display part of the Reference data type to hold the name of the practitioner - use the reference to point to a CareConnect-Practitioner-1 - use the reference to point to the Organization (pharmacy)
valueQuantity	0..1	The weight recorded in kilogrammes
dataAbsentReason	0..1	An optional reason why the data is absent
comment	0..1	Any additional comments
bodySite	0..1	Optional body site of reading

Weight Observation Example

Note: These examples have not been clinically assured against Digital Medicines use cases.
Examples are illustrative only.

<!--<xml>--> 
<Observation xmlns="http://hl7.org/fhir">
	<id value="dbbad20f-e696-405e-8c98-be0cdcc5406c"/>
	<meta>
		<!--claims conformance to CareConnect-Observation-1-->
		<profile value="https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Observation-1"/>
	</meta>
	<!--fixed value for status-->
	<status value="final"/>
	<!--fixed value for category-->
	<category>
		<coding>
			<system value="http://hl7.org/fhir/observation-category"/>
			<code value="vital-signs"/>
			<display value="Vital Signs"/>
		</coding>
	</category>
	<!--fixed values for code-->
	<code>
		<coding>
			<system value="http://loinc.org"/>
			<code value="29463-7"/>
			<display value="Body weight"/>
		</coding>
		<coding>
			<system value="http://snomed.info/sct"/>
			<code value="27113001 "/>
			<display value="Body weight"/>
		</coding>
	</code>
	<!--link to patient-->
	<subject>
		<reference value="Patient/4f78d392-c9e0-4f1f-9ab6-57d387838690"/>
	</subject>
	<!--date time when reading occurred-->
	<effectiveDateTime value="2018-10-04T14:17:59+01:00"/>
	<!--the performer-->
	<performer>
		<reference value="Performer/2360aba6-8561-4a22-bbbf-afc08e750146"/>
	</performer>
	<performer>
		<reference value="Organization/cd5f7770-6249-4f5d-ad8e-d0bb1446a4d9"/>
	</performer>
	<!--the reading-->
	<valueQuantity>
		<value value="82.7"/>
		<unit value="kg"/>
		<system value="http://unitsofmeasure.org"/>
	</valueQuantity>
</Observation>
<!--</xml>-->

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Oxygen Saturation Observation

The coded form of each oxygen saturation reading follows the codes and structure for CareConnect-OxygenSaturation-Observation-1.

CareConnect-Observation-1 element	Cardinality	Notes
meta.profile	1..1	Claim conformance to ‘https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-OxygenSaturation-Observation-1’
status	1..1	Fixed to final
category	1..1	Fixed as per profile
code	1..1	Loinc slice – fixed as per profile SNOMED slice – fixed as per profile
subject	1..1	Link to Patient
effectiveDateTime	1..1	The date and time the reading took place
performer	0..*	Either - use the identifier part of Reference data type to hold the identifier of the practitioner - use the display part of the Refer4ence data type to hold the name of the practitioner - use the reference to point to a CareConnect-Practitioner-1 - use the reference to point to the Organization (pharmacy)
valueQuantity	0..1	The temperature recorded in percent
dataAbsentReason	0..1	An optional reason why the data is absent
comment	0..1	Any additional comments
bodySite	0..1	Optional body site of reading

Oxygen Saturation Observation Example

Note: These examples have not been clinically assured against Digital Medicines use cases.
Examples are illustrative only.

<!--<xml>--> 
<Observation xmlns="http://hl7.org/fhir">
	<id value="35a1483b-4d04-4907-9f4e-c69ae409a1ea"/>
	<meta>
		<!--claims conformance to CareConnect-OxygenSaturation-Observation-1-->
		<profile value="https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-OxygenSaturation-Observation-1"/>
	</meta>
	<!--fixed to final-->
	<status value="final"/>
	<!--fixed value for category-->
	<category>
		<coding>
			<system value="http://hl7.org/fhir/observation-category"/>
			<code value="vital-signs"/>
			<display value="Vital Signs"/>
		</coding>
	</category>
	<!--fixed values for code-->
	<code>
		<coding>
			<system value="http://loinc.org"/>
			<code value="59408-5"/>
			<display value="Oxygen saturation in Arterial blood by Pulse oximetry"/>
		</coding>
		<coding>
			<system value="http://snomed.info/sct"/>
			<code value="103228002"/>
			<display value="Hemoglobin saturation with oxygen"/>
		</coding>
	</code>
	<!--link to patient-->
	<subject>
		<reference value="Patient/4f78d392-c9e0-4f1f-9ab6-57d387838690"/>
	</subject>
	<effectiveDateTime value="2018-10-04T14:17:59+01:00"/>
	<!--practitioner-->
	<performer>
		<reference value="Performer/2360aba6-8561-4a22-bbbf-afc08e750146"/>
	</performer>
	<performer>
		<reference value="Organization/cd5f7770-6249-4f5d-ad8e-d0bb1446a4d9"/>
	</performer>
	<!--the reading-->
	<valueQuantity>
		<value value="93"/>
		<unit value="%"/>
		<system value="http://unitsofmeasure.org"/>
	</valueQuantity>
</Observation>
<!--</xml>-->

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Pain Score Observation

The coded form of each pain score reading follows the codes and structure for CareConnect-Observation-1.

CareConnect-Observation-1 element	Cardinality	Notes
meta.profile	1..1	Claim conformance to ‘https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Observation-1’
status	1..1	Fixed to final
code	1..1	Fixed as demonstrated in example below
subject	1..1	Link to Patient
effectiveDateTime	1..1	The date and time the reading took place
performer	0..*	Either - use the identifier part of Reference data type to hold the identifier of the practitioner - use the display part of the Reference data type to hold the name of the practitioner - use the reference to point to a CareConnect-Practitioner-1 - use the reference to point to the Organization (pharmacy)
valueQuantity	0..1	The recorded pain score value
dataAbsentReason	0..1	An optional reason why the data is absent
comment	0..1	Any additional comments
method	1..1	The pain scale used

Pain Score Observation Example

Note: These examples have not been clinically assured against Digital Medicines use cases.
Examples are illustrative only.

<!--<xml>-->
<Observation xmlns="http://hl7.org/fhir">
	<id value="dbbad20f-e696-405e-8c98-be0cdcc5406c"/>
	<meta>
		<!--claims conformance to CareConnect-BodyTemperature-Observation-1-->
		<profile value="https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Observation-1"/>
	</meta>
	<!--fixed value for status-->
	<status value="final"/>
	<!--fixed values for code-->
	<code>
		<coding>
			<system value="http://snomed.info/sct"/>
			<code value="225908003"/>
			<display value="Pain score"/>
		</coding>
	</code>
	<!--link to patient-->
	<subject>
		<reference value="Patient/4f78d392-c9e0-4f1f-9ab6-57d387838690"/>
	</subject>
	<!--date time when reading occurred-->
	<effectiveDateTime value="2018-10-04T14:17:59+01:00"/>
	<!--the performer-->
	<performer>
		<reference value="Performer/2360aba6-8561-4a22-bbbf-afc08e750146"/>
	</performer>
	<performer>
		<reference value="Organization/cd5f7770-6249-4f5d-ad8e-d0bb1446a4d9"/>
	</performer>
	<!--the reading-->
	<valueQuantity>
		<value value="4"/>
	</valueQuantity>
	<method>
		<text value="Verbal Rating Scale"/>
	</method>
</Observation>
<!--</xml>-->

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Level of Consciousness Observation

The coded form of each Level of Consciousness reading follows the codes and structure the codes and structure for CareConnect-ACVPU-Observation-1.

CareConnect-Observation-1 element	Cardinality	Notes
meta.profile	1..1	Claim conformance to ‘https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-ACVPU-Observation-1’
status	1..1	Fixed to final
code	1..1	SNOMED slice – fixed as per profile
subject	1..1	Link to Patient
effectiveDateTime	1..1	The date and time the reading took place
performer	0..*	Either - use the identifier part of Reference data type to hold the identifier of the practitioner - use the display part of the Reference data type to hold the name of the practitioner - use the reference to point to a CareConnect-Practitioner-1 - use the reference to point to the Organization (pharmacy)
valueCodeableConcept	0..1	The Consciousness recorded in percent – one of - alert - confusion - voice - pain - unresponsive
dataAbsentReason	0..1	An optional reason why the data is absent
comment	0..1	Any additional comments
bodySite	0..1	Optional body site of reading

Level of Consciousness Observation Example

Note: These examples have not been clinically assured against Digital Medicines use cases.
Examples are illustrative only.

<!--<xml>-->
<Observation xmlns="http://hl7.org/fhir">
	<id value="dbbad20f-e696-405e-8c98-be0cdcc5406c"/>
	<meta>
		<!--claims conformance to CareConnect-ACVPU-Observation-1-->
		<profile value="https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-ACVPU-Observation-1"/>
	</meta>
	<!--fixed value for status-->
	<status value="final"/>
	<!--fixed values for code-->
	<code>
		<coding>
			<system value="http://snomed.info/sct"/>
			<code value="1104441000000107"/>
			<display value="ACVPU (Alert Confusion Voice Pain Unresponsive) scale score"/>
		</coding>
	</code>
	<!--link to patient-->
	<subject>
		<reference value="Patient/4f78d392-c9e0-4f1f-9ab6-57d387838690"/>
	</subject>
	<!--date time when reading occurred-->
	<effectiveDateTime value="2018-10-04T14:17:59+01:00"/>
	<!--the performer-->
	<performer>
		<reference value="Performer/2360aba6-8561-4a22-bbbf-afc08e750146"/>
	</performer>
	<performer>
		<reference value="Organization/cd5f7770-6249-4f5d-ad8e-d0bb1446a4d9"/>
	</performer>
	<!--the reading-->
	<valueCodeableConcept>
		<code>
			<coding>
				<code value="voice"/>
			</coding>
		</code>
	</valueCodeableConcept>
</Observation>
<!--</xml>-->

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Respiratory Rate Observation

The coded form of each respiratory rate reading follows the codes and structure for CareConnect-RespiratoryRate-Observation-1.

CareConnect-Observation-1 element	Cardinality	Notes
meta.profile	1..1	Claim conformance to ‘https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-RespiratoryRate-Observation-1’
status	1..1	Fixed to final
category	1..1	Fixed as per profile
code	1..1	Loinc slice – fixed as per profile SNOMED slice – fixed as per profile
subject	1..1	Link to Patient
effectiveDateTime	1..1	The date and time the reading took place
performer	0..*	Either - use the identifier part of Reference data type to hold the identifier of the practitioner - use the display part of the Reference data type to hold the name of the practitioner - use the reference to point to a CareConnect-Practitioner-1 - use the reference to point to the Organization (pharmacy)
valueQuantity	0..1	The respiratory rate recorded in /min
dataAbsentReason	0..1	An optional reason why the data is absent
comment	0..1	Any additional comments
bodySite	0..1	Optional body site of reading

Respiratory Rate Observation Example

Note: These examples have not been clinically assured against Digital Medicines use cases.
Examples are illustrative only.

<!--<xml>-->
<Observation xmlns="http://hl7.org/fhir">
	<id value="3a3fce15-32d6-4911-86f9-6f849066e0c1"/>
	<meta>
		<profile value="https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-RespiratoryRate-Observation-1"/>
	</meta>
	<status value="final"/>
	<category>
		<coding>
			<system value="http://hl7.org/fhir/observation-category"/>
			<code value="vital-signs"/>
			<display value="Vital Signs"/>
		</coding>
	</category>
	<code>
		<coding>
			<system value="http://loinc.org"/>
			<code value="9279-1"/>
			<display value="Respiratory Rate"/>
		</coding>
		<coding>
			<system value="http://snomed.info/sct"/>
			<code value="86290005"/>
			<display value="Respiratory rate"/>
		</coding>
	</code>
	<subject>
		<reference value="Patient/4f78d392-c9e0-4f1f-9ab6-57d387838690"/>
	</subject>
	<effectiveDateTime value="2018-10-04T14:17:59+01:00"/>
	<performer>
		<reference value="Performer/2360aba6-8561-4a22-bbbf-afc08e750146"/>
	</performer>
	<performer>
		<reference value="Organization/cd5f7770-6249-4f5d-ad8e-d0bb1446a4d9"/>
	</performer>
	<valueQuantity>
		<value value="21"/>
		<unit value="/min"/>
		<system value="http://unitsofmeasure.org"/>
	</valueQuantity>
</Observation>
<!--</xml>-->

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Air or Oxygen Observation

CareConnect-Observation-1 element	Cardinality	Notes
meta.profile	1..1	Claim conformance to ‘https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Observation-1’
status	1..1	Fixed to final
code	1..1	Use the text element of CodeableConcept to indicate an ‘Air or Oxygen Observation’
subject	1..1	Link to Patient
effectiveDateTime	1..1	The date and time the reading took place
performer	0..*	Either - use the identifier part of Reference data type to hold the identifier of the practitioner - use the display part of the Reference data type to hold the name of the practitioner - use the reference to point to a CareConnect-Practitioner-1 - use the reference to point to the Organization (pharmacy)
valueCodeableConcept	0..1	One of - 722742002 ‘Breathing room air’ OR - 371825009 ‘Patient on oxygen’ OR - 315041000 ‘High concentration oxygen therapy (procedure)’ OR - 9999016 ‘High flow oxygen therapy (procedure)’
dataAbsentReason	0..1	An optional reason why the data is absent
comment	0..1	Any additional comments

Air or Oxygen Observation Example

Note: These examples have not been clinically assured against Digital Medicines use cases.
Examples are illustrative only.

<!--<xml>-->
<Observation xmlns="http://hl7.org/fhir">
	<id value="3a3fce15-32d6-4911-86f9-6f849066e0c1"/>
	<meta>
		<profile value="https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Observation-1"/>
	</meta>
	<status value="final"/>
	<code>
		<text value=”Air or Oxygen Observation”>
	</code>
	<subject>
		<reference value="Patient/4f78d392-c9e0-4f1f-9ab6-57d387838690"/>
	</subject>
	<effectiveDateTime value="2018-10-04T14:17:59+01:00"/>
	<performer>
		<reference value="Performer/2360aba6-8561-4a22-bbbf-afc08e750146"/>
	</performer>
	<performer>
		<reference value="Organization/cd5f7770-6249-4f5d-ad8e-d0bb1446a4d9"/>
	</performer>
	<valueCodeableConcept>
		<system value="http://snomed.info/sct"/>
		<code value="722742002"/>
		<display value="Breathing room air"/>
	</valueCodeableConcept >
</Observation>
<!--</xml>-->

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NEWS2 Score Observation

The coded form of each NEWS2 observation follows the code and structure for CareConnect-Observation-1.

CareConnect-Observation-1 element	Cardinality	Notes
meta.profile	1..1	Claim conformance to ‘https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Observation-1’
status	1..1	Fixed to final
category	1..1	Fixed as demonstrated in example below
code	1..1	Fixed as demonstrated in example below
subject	1..1	Link to Patient
effectiveDateTime	1..1	The date and time the reading took place
performer	0..*	Either - use the identifier part of Reference data type to hold the identifier of the practitioner - use the display part of the Reference data type to hold the name of the practitioner - use the reference to point to a CareConnect-Practitioner-1 - use the reference to point to the Organization (pharmacy)
valueQuantity	0..1	The NEWS2 score recorded
related	0..*	Links to the Observations that make up the NEWS2 score
component	0..*	Components detailing the sub-score – as demonstrated in example below. The values for the sub-score codes are: - 1104351000000103 ‘Royal College of Physicians NEWS2 (National Early Warning Score 2) - pulse score’ - 1104311000000102 ‘Royal College of Physicians NEWS2 (National Early Warning Score 2) - oxygen saturation scale 1 score’ - 1104331000000105 ‘Royal College of Physicians NEWS2 (National Early Warning Score 2) - air or oxygen score’ - 1104371000000107 ‘Royal College of Physicians NEWS2 (National Early Warning Score 2) - temperature score’ - 1104341000000101 ‘Royal College of Physicians NEWS2 (National Early Warning Score 2) - systolic blood pressure score’ - 1104361000000100 ‘Royal College of Physicians NEWS2 (National Early Warning Score 2) - consciousness score’

NEWS2 Score Observation Example

Note: These examples have not been clinically assured against Digital Medicines use cases.
Examples are illustrative only.

<!--<xml>-->
<Observation>
	<id value="21344a45-2660-45d1-9fb3-49e54d14b662"/>
	<meta>
		<profile value="https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Observation-1"/>
	</meta>
	<identifier>
		<system value="https://tools.ietf.org/html/rfc4122"/>
		<value value="7188c7ad-7802-4d43-9775-4d9d684600d5"/>
	</identifier>
	<status value="final"/>
	<category>
		<coding>
			<system value="http://terminology.hl7.org/CodeSystem/observation-category"/>
			<code value="survey"/>
			<display value="Survey"/>
		</coding>
	</category>
	<code>
		<coding>
			<system value="http://snomed.info/sct"/>
			<code value="1104051000000101"/>
			<display value="Royal College of Physicians NEWS2 (National Early Warning Score 2) total score"/>
		</coding>
	</code>
	<subject>
		<reference value="Patient/ad2c58ab-ffab-4366-9c76-b0322e22e881"/>
	</subject>
	<effectiveDateTime value="2018-10-04T14:17:59+01:00"/>
	<performer>
		<reference value="Performer/7096e518-2638-4c00-ab0e-504c20cd50b6"/>
	</performer>
	<performer>
		<reference value="Organization/25d5ad55-5657-4cbe-9b8b-2e993f19286e"/>
	</performer>
	<valueQuantity>
		<value value="6"/>
		<system value="http://unitsofmeasure.org"/>
		<code value="score"/>
	</valueQuantity>
	<related>
		<type value="derived-from"/>
		<target>
			<reference value="Observation/fc6c6fa5-d8e8-4634-a19a-985325077cb2"/>
		</target>
	</related>
	<related>
		<type value="derived-from"/>
		<target>
			<reference value="Observation/638c6821-eb51-4f1b-b8c0-5269d1df9b7c"/>
		</target>
	</related>
	<related>
		<type value="derived-from"/>
		<target>
			<reference value="Observation/5a1625e8-938e-4c19-9d3e-a235bfb4b37d"/>
		</target>
	</related>
	<related>
		<type value="derived-from"/>
		<target>
			<reference value="Observation/c756fd32-f04e-45a9-b02f-2461ed53c736"/>
		</target>
	</related>
	<related>
		<type value="derived-from"/>
		<target>
			<reference value="Observation/1a1273f4-dd78-4bb4-bb98-ed6456caa2a2"/>
		</target>
	</related>
	<related>
		<type value="derived-from"/>
		<target>
			<reference value="Observation/f0d26102-3a50-4993-9203-6089b625fc2f"/>
		</target>
	</related>
	<related>
		<type value="derived-from"/>
		<target>
			<reference value="Observation/dbf6ec86-ebd7-4490-8586-596328519ed2"/>
		</target>
	</related>
	<!-- Respiratory Rate Sub-Score -->
	<component>
		<code>
			<coding>
				<system value="http://snomed.info/sct"/>
				<code value="1104301000000104"/>
				<display value="Royal College of Physicians NEWS2 (National Early Warning Score 2) - respiration rate score"/>
			</coding>
		</code>
		<valueQuantity>
			<value value="2"/>
			<system value="http://unitsofmeasure.org"/>
			<code value="score"/>
		</valueQuantity>
	</component>
	<!-- Pulse Sub-Score -->
	<component>
		<code>
			<coding>
				<system value="http://snomed.info/sct"/>
				<code value="1104351000000103"/>
				<display value="Royal College of Physicians NEWS2 (National Early Warning Score 2) - pulse score"/>
			</coding>
		</code>
		<valueQuantity>
			<value value="1"/>
			<system value="http://unitsofmeasure.org"/>
			<code value="score"/>
		</valueQuantity>
	</component>
	<!-- Oxygen Saturation scale 1 Sub-Score -->
	<component>
		<code>
			<coding>
				<system value="http://snomed.info/sct"/>
				<code value="1104311000000102"/>
				<display value="Royal College of Physicians NEWS2 (National Early Warning Score 2) - oxygen saturation scale 1 score"/>
			</coding>
		</code>
		<valueQuantity>
			<value value="2"/>
			<system value="http://unitsofmeasure.org"/>
			<code value="score"/>
		</valueQuantity>
	</component>
	<!-- Air or Oxygen Sub-Score -->
	<component>
		<code>
			<coding>
				<system value="http://snomed.info/sct"/>
				<code value="1104331000000105"/>
				<display value="Royal College of Physicians NEWS2 (National Early Warning Score 2) - air or oxygen score"/>
			</coding>
		</code>
		<valueQuantity>
			<value value="0"/>
			<system value="http://unitsofmeasure.org"/>
			<code value="score"/>
		</valueQuantity>
	</component>
	<!-- Temperature Sub-Score -->
	<component>
		<code>
			<coding>
				<system value="http://snomed.info/sct"/>
				<code value="1104371000000107"/>
				<display value="Royal College of Physicians NEWS2 (National Early Warning Score 2) - temperature score"/>
			</coding>
		</code>
		<valueQuantity>
			<value value="1"/>
			<system value="http://unitsofmeasure.org"/>
			<code value="score"/>
		</valueQuantity>
	</component>
	<!-- Systolic Blood Pressure Sub-Score -->
	<component>
		<code>
			<coding>
				<system value="http://snomed.info/sct"/>
				<code value="1104341000000101"/>
				<display value="Royal College of Physicians NEWS2 (National Early Warning Score 2) - systolic blood pressure score"/>
			</coding>
		</code>
		<valueQuantity>
			<value value="0"/>
			<system value="http://unitsofmeasure.org"/>
			<code value="score"/>
		</valueQuantity>
	</component>
	<!--  Consciousness Sub-Score -->
	<component>
		<code>
			<coding>
				<system value="http://snomed.info/sct"/>
				<code value="1104361000000100"/>
				<display value="Royal College of Physicians NEWS2 (National Early Warning Score 2) - consciousness score"/>
			</coding>
		</code>
		<valueQuantity>
			<value value="0"/>
			<system value="http://unitsofmeasure.org"/>
			<code value="score"/>
		</valueQuantity>
	</component>
</Observation>
<!--</xml>-->

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Tags: fhir